Tuesday, June 9, 2015

Dr. Orthochick: Help

I had a really bad call the other week of the variety where I couldn't do anything right. And it was busy so I kept on having to double back because I was redoing a lot of stuff. Around 1 in the AM I got consulted for a guy with a finger infection, he had been bit by another person and some genius in the ER had sewed it up so that the infection brewed deep to the sutures and ravaged his pinky. I looked at it and he seemed to have infection diffusely--the whole finger was swollen and he couldn't move it and he had erythema and lymph nodes tracking past his elbow. So I didn't really feel like I could handle the situation on my own in the ER, and I say this as the chick who once washed out a septic wrist in the ER. (Disclaimer: Even at the time I knew that was a bad idea)

The problem was, the hand surgeon on call that night was Dr. Ortho. I don't like Dr. Ortho, he doesn't like me, I spend a decent amount of time and effort trying to stay out of his way. So I really didn't want to call him to tell him I needed help, but since the alternative was make a mess out of everything, I gritted my teeth and told myself it was in the patient's best interest.

What I wanted to say was, the reason why I was scared to do this was because i had a similar patient with Dr. Pregnant at the beginning of the year and I tried washing him out on my own in the ER. I made a small incision in the base of the finger the way you're supposed to and tried flushing out the sheath, but the infection seemed a little too diffuse for that so I wound up flaying open his finger. I made zigzagging cuts across the palm of the index finger and created flaps. At some point in all that, I must have hit one of the digital artery and nerve bundles (you have 2, one on each side of your finger) and knocked them out. I remember a lot of bleeding and trying to get it under control. Anyway, because he had reduced blood supply to his finger, the antibiotics couldn't get to his finger and the tip died off from lack of blood and infection. The flaps I had created on his palm turned black and fell off because they didn't have enough blood. We took him back to the operating room to try and save something, but we saw pus dripping off his other digital nerve and artery. We couldn't clean them off because we wanted to save at least one in the hopes that his finger wouldn't die, which meant that we left pus to rot in his finger. He lost his index finger. He was 35 and a laborer.

So I wanted to tell Dr. Ortho that story, but I didn't want to admit that it was my fault that a healthy young guy lost a finger and even though I have a better idea of what to do now, I was scared. So he came in to do it with me, after berating me over the phone for a good 10 minutes for not knowing how to do a flexor tenosynovitis/septic arthritis washout by this point in my education. He came in to the ER at 2AM, washed out the guy's finger without talking to me, turned to me at the end of the hour and said "write admission orders and dictate this procedure," and then walked out without looking back.

I know I should know how to do this by now, and it's not that I don't per se, but I really don't think it's the worst thing in the world to ask for help.


  1. I can't stand attendings like that. You're in training for a reason. You weren't wrong and you were doing what was in the patient's best interests.

  2. Your attending was a jerk, plain and simple. As trainees, we should always be able to call for backup when we need it. Even once we're staff we should have a collegial environment where we can discuss difficult cases with our colleagues. We're all learning - always.

  3. Good for you for not letting your pride get in the way of the patient's best interest. Wow that story brings back memories of training. I try really hard to be understanding when a trainee simply needs help and support from me, regardless of time of night.

  4. You did right by the patient, and it was especially brave, considering you knew you'd be reamed for it.

  5. How would you know how to do a procedure "by this time in your education" if no one had ever taught you or if you happened to have never seen a patient with this issue? Attendings in teaching hospitals are mandated to TEACH. More fundamentally, they're required to supervise residents in all aspects to ensure patients get safe, appropriate care. This responsibility is bundled into their salary as the hospital gets federal funding for resident slots.

    They may at times wish you had an attending level of knowledge and experience, but it's their job to help you get it even when it deprives them of time, sleep, food, or other aspects of well-being.

    I'd be so pissed off if I suffered a major complication because the attending didn't care to supervise the resident or otherwise put up barriers to the resident asking for help. Residents shouldn't have to weigh the pros and cons of calling the attending in a potentially urgent or emergent situation.

  6. I second what PGYx said. Your pride and the attending's bad attitude come second to the interests of the patient. That said, it sounded like that infected finger was doomed the moment the last stitch went in back in the ER.

  7. The world doesn't need anymore puffed up bozos, but at least he came and did his job. Albeit reluctantly.

  8. Everything everyone else said. This is why medicine gets the bad reputation that it deserves. Be human. Many of us will thank you for it. I'm one of those who does bring up good docs to admin attention.

    A lot.

  9. Knowing when to ask for help is one of the most valuable skills to have as a doctor. You have to know your limitations, so that your patients get the best possible care.

  10. Interesting.

    I'd be curious to know how long between bite and suture. There's nothing inherently wrong in suturing a bite if it's a short time since the injury and it's not already infected. You'd put them on some antibiotics of course.

    Sadly, this kind of attending douchebaggery is exceptionally common, especially, for whatever reason, in the surgical specialities.

    In EM we are at ground zero for all the consultants who don't want to come in and do their jobs. So we feel your pain.

  11. Earlier this week I was talked through my first chest drain. Stepped through like a baby in fact where they pointed and I just followed all instructions. Up to the point of puncturing the pleura. At that point they took over because "I took too long".
    So the first tube coiled around, likely extra pleural.
    The second tube another doctor placed went extra pleural into the mediastinum causing pneumothorax and pneumomediastinum.
    The third CXR (?after fiddling) had mediastinal shift.

    The supervising consultant has ranted at me every time I've seen him about poor line placement even though I cut exactly where told to and didn't actually insert any of the lines myself. It's really blunted my enthusiasm for all procedures.